Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 18-03390-178 | Follow-Up Review of the Veterans Crisis Line, Canandaigua, New York; Atlanta, Georgia; and Topeka, Kansas | Hotline Healthcare Inspection | ||
1 The Veterans Crisis Line director ensures analysis of rescue efforts ending because the caller’s location cannot be found, identifies and analyzes metrics that may have contributed to the inability to locate these rescues, and takes remedial action.
Closure Date:
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| 17-03557-177 | Episodes of Non-Adherence to Privacy and Security Policies at the Tibor Rubin VA Medical Center, Long Beach, California | Hotline Healthcare Inspection | ||
1 The Tibor Rubin VA Medical Center Director reviews the communication processes between employees and Biomedical Engineering and Information Technology departments regarding disclosure of patient sensitive information when interface issues exist and takes necessary actions to improve this communication.
Closure Date:
2 The Tibor Rubin VA Medical Center Director ensures that facility healthcare staff can identify which patient information or combination of patient information is considered protected from disclosure and staff transfers protected information across all communication modes, including emails and text pages, according to VA/Veterans Health Administration policy.
Closure Date:
3 The Tibor Rubin VA Medical Center Director ensures that the Privacy Officer and the Information Systems Security Officer take necessary steps when protected patient information is compromised or possibly breached.
Closure Date:
4 The Tibor Rubin VA Medical Center Director considers offering credit monitoring to the 133 identified patients.
Closure Date:
5 The VA Assistant Secretary for Information and Technology reviews and adjusts the Veterans Administration Handbook 6500.2, Management of Breaches Involving Sensitive Personal Information, to include a process and guidance to address sensitive personal information incidents and events such as the use of personal email systems to transfer and store patient sensitive information and texting with personal cell phones.
Closure Date:
6 The Tibor Rubin VA Medical Center Director reviews the facility’s policy and use of physical logbooks and ensures compliance with Veterans Health Administration policy.
Closure Date:
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| 19-06386-179 | Factors Contributing to the Death of a Ventilator-Dependent Patient at the VA San Diego Healthcare System, California | Hotline Healthcare Inspection | ||
1 The VA San Diego Healthcare System Director ensures that a policy is developed, staff is trained, and compliance is monitored related to the use of the Passy-Muir® Valve on the Spinal Cord Injury unit to include:
a) Staff education on ventilator alarm settings when an in-line Passy-Muir® Valve is used,
b) Documentation and monitoring of ventilator settings before, during, and after Passy-Muir® Valve use,
c) Documentation of length of time the Passy-Muir® Valve is in place,
d) Back-up plan for monitoring patients on a Passy-Muir® Valve,
e) Patient supervision while using the Passy-Muir® Valve, and
f) Patient and family education on the safe use of the Passy-Muir® Valve.
Closure Date:
2 The VA San Diego Healthcare System Director ensures that a policy is developed for the use of ventilator anti-disconnect devices, that staff are trained, and that compliance is monitored.
Closure Date:
3 The VA San Diego Healthcare System Director confers with the National Center for Patient Safety to determine if a National Patient Safety Advisory should be issued regarding a potential deficit in training for staff who care for ventilated patients in non-intensive care unit settings.
Closure Date:
4 The VA San Diego Healthcare System Director ensures that Spinal Cord Injury and respiratory therapy staff are provided refresher training regarding issues to report to the Patient Safety program.
Closure Date:
5 The VA San Diego Healthcare System Director ensures that Spinal Cord Injury leadership reviews clinical alarms annually and ensures that the review is discussed and documented in Spinal Cord Injury Leadership Committee minutes.
Closure Date:
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| 18-05731-176 | Concerns Related to an Inpatient’s Response to Oxycodone and Facility Actions at the Baltimore VA Medical Center, Maryland | Hotline Healthcare Inspection | ||
1 The VA Maryland Health Care System director takes steps to ensure resident supervision meets requirements, and monitors for compliance with Veterans Health Administration policy.
Closure Date:
2 The VA Maryland Health Care System director verifies the capture and reporting of adverse drug events to the national Veterans Health Administration Adverse Drug Event Reporting System, and monitors for compliance.
Closure Date:
3 The VA Maryland Health Care System director ensures staff complete root cause analyses or aggregated reviews for adverse events as required by Veterans Health Administration policy and monitors to ensure completion.
Closure Date:
4 The VA Maryland Health Care System director verifies documentation of clinical disclosures when perceptible effects of an adverse event have occurred, as required, and monitors for compliance.
Closure Date:
5 The VA Maryland Health Care System director ensures peer reviews are evaluated according to VA Maryland Health Care System policy and monitors for compliance.
Closure Date:
6 The VA Maryland Health Care System director verifies that the Surgical Work Group meets and documents minutes as required to include improvement data presentation, discussion, and performance tracking, and monitors for compliance.
Closure Date:
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| 18-04924-112 | Program of Comprehensive Assistance for Family Caregivers: Timely Discharges, But Oversight Needs Improvement | Audit | ||
1 The Under Secretary for Health establishes processes to conduct matching, at least quarterly, of the records of enrolled veterans and their caregivers against the Department of Veterans Affairs’ death, incarceration, and hospitalization data to help ensure timely program discharges and to reduce the risk of improper and questionable payments.
Closure Date:
2 The Under Secretary for Health takes steps to outline in the program’s roles and responsibilities document what the veteran and caregiver responsibilities are for promptly notifying caregiver support coordinators of deaths.
Closure Date:
3 The Under Secretary for Health institutes a program working group to clarify inconsistencies and gaps in program guidance. Specifically, the working group should determine if incarcerated or hospitalized veterans or caregivers should adhere to different discharge requirements. The working group should also consider the time frames for discharges, a process for veterans and caregivers to reapply to or be suspended from the program following a discharge due to incarceration or hospitalization, and should initiate updating program guidance accordingly.
Closure Date:
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| 19-00007-168 | Comprehensive Healthcare Inspection of the Amarillo VA Health Care System, Texas | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.
Closure Date:
2 The chief of staff ensures the Cardio Resuscitation Committee reviews each resuscitative episode for which the facility is responsible and monitors the committee’s compliance.
Closure Date:
3 The chief of staff ensures that provider privileges contain a clearly delineated timeframe not to exceed two years and monitors compliance.
Closure Date:
4 The chief of staff makes certain that service chiefs establish and define focused professional practice evaluation criteria that include the minimum required specialty criteria, as applicable, prior to initiation of the evaluations and monitors service chiefs’ compliance.
Closure Date:
5 The chief of staff confirms that service chiefs initiate and complete focused professional practice evaluations that include clearly delineated timeframes and monitors service chiefs’ compliance.
Closure Date:
6 The chief of staff ensures that the Medical Executive Board documents consideration of focused professional practice evaluation results in its decision to recommend approval of requested privileges and monitors the Medical Executive Board’s compliance.
Closure Date:
7 The chief of staff confirms that service chiefs include the review of service-specific data for ongoing professional practice evaluations and monitors service chiefs’ compliance.
Closure Date:
8 The chief of staff makes certain that service chiefs consistently collect and review ongoing professional practice evaluation data and monitors service chiefs’ compliance.
Closure Date:
9 The chief of staff ensures that the Medical Executive Board documents its decision to recommend continuing privileges based on ongoing professional practice evaluation results and monitors the board’s compliance.
Closure Date:
10 The associate director ensures staff store expired medications separately from medications available for administration and label medication vials with an expiration date upon opening and monitors staff’s compliance.
Closure Date:
11 The associate director ensures that staff store clean and dirty medical equipment and supplies separately and monitors compliance.
Closure Date:
12 The associate director ensures that managers test all emergency power outlets and monitors managers’ compliance.
Closure Date:
13 The chief of staff ensures the military sexual trauma coordinator tracks military sexual trauma-related staff training and monitors the coordinator’s compliance.
Closure Date:
14 The chief of staff ensures the military sexual trauma coordinator communicates the status of military sexual trauma-related information to leaders and monitors the coordinator’s compliance.
Closure Date:
15 The chief of staff ensures providers complete military sexual trauma mandatory training within the required timeframe and monitors providers’ compliance.
Closure Date:
16 The chief of staff makes certain that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and monitors the clinicians’ compliance.
Closure Date:
17 The facility director confirms that the Women Veterans Health Committee includes required core members and monitors the committee’s compliance.
Closure Date:
18 The chief of staff makes certain that program managers implement a process to track results reporting and follow-up care data for cervical cancer screenings and monitors program managers’ compliance.
Closure Date:
19 The chief of staff ensures that ordering providers communicate abnormal results to patients within the required timeframe and monitors providers’ compliance.
Closure Date:
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| 18-04680-162 | Comprehensive Healthcare Inspection of the Cheyenne VA Medical Center, Wyoming | Comprehensive Healthcare Inspection Program | ||
1 The facility director ensures the interdisciplinary group or committee that reviews utilization management data includes a representative from the chief business office revenue utilization review and monitors the committee’s compliance.
Closure Date:
2 The facility director ensures the patient safety manager includes all required review elements in root cause analyses and monitors the patient safety manager’s compliance.
Closure Date:
3 The facility director confirms that the Critical Care Committee conducts a complete analysis of resuscitation episodes by reviewing required elements and monitors the committee’s compliance.
Closure Date:
4 The chief of staff ensures service chiefs collect, review, and use ongoing professional practice evaluation data in the determination to continue current privileges and monitors the service chiefs’ compliance.
Closure Date:
5 The chief of staff makes certain service chiefs include the minimum required specialty-specific criteria for ongoing professional practice evaluations of gastroenterology practitioners and monitors service chiefs’ compliance.
Closure Date:
6 The chief of staff makes certain that ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors compliance.
Closure Date:
7 The associate director ensures managers maintain a safe and clean environment in patient care areas and monitors managers’ compliance.
Closure Date:
8 The associate director ensures managers make personal protective equipment readily accessible to employees at the Rawlins VA Clinic and monitors managers’ compliance.
Closure Date:
9 The associate director makes certain that the hazard vulnerability analysis is reviewed annually and monitors compliance.
Closure Date:
10 The associate director confirms that the emergency operations plan is activated twice a year and monitors compliance.
Closure Date:
11 The facility director ensures the military sexual trauma coordinator establishes and monitors military sexual trauma-related staff training and monitors the coordinator’s compliance.
Closure Date:
12 The facility director ensures the military sexual trauma coordinator communicates the status of military sexual trauma-related services and initiatives with leadership and monitors the coordinator’s compliance.
Closure Date:
13 The facility director makes certain that the military sexual trauma coordinator tracks and monitors military sexual trauma-related data and monitors the coordinator’s compliance.
Closure Date:
14 The chief of staff ensures that providers complete military sexual trauma mandatory training within the required timeframe and monitors providers’ compliance.
Closure Date:
15 The chief of staff confirms that clinicians provide and document patient/caregiver education and assess understanding of education provided about newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
16 The facility director makes certain that the Women Veterans Health Committee includes required core members and monitors the committee’s compliance.
Closure Date:
17 The associate director for Patient Care Services makes certain that staff label multi-dose medication vials with an expiration date upon opening and monitors clinical staff’s compliance.
Closure Date:
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| 17-05572-170 | Concerns with Access and Delays in Outpatient Mental Health Care at the New Mexico VA Health Care System, Albuquerque, New Mexico | Hotline Healthcare Inspection | ||
1 The New Mexico VA Health Care System Director ensures that outpatient mental health scheduling staff receive training to use the electronic wait list as required by Veterans Health Administration and that New Mexico VA Health Care System managers monitor compliance.
Closure Date:
2 The New Mexico VA Health Care System Director reviews clinic cancellation rates and develops action plans to address identified issues.
Closure Date:
3 The New Mexico VA Health Care System Director reviews open and completed consult data as well as new patient data and develops action plans to address identified issues.
Closure Date:
4 The New Mexico VA Health Care System Director evaluates the underutilization of non-VA and telemental health services for the outpatient mental health department and develops an action plan to address identified issues.
Closure Date:
5 The New Mexico VA Health Care System Director ensures that patients with outpatient mental health consults and return-to-clinic orders, including telemental health, are scheduled as required by Veterans Health Administration policy and within the Veterans Health Administration consult/return-to-clinic timeframe and that the scheduling process is monitored for compliance.
Closure Date:
6 The New Mexico VA Health Care System Director and managers review provider and scheduling staffing levels and develop an action plan to address recommendations, if any, from the staffing level reviews.
Closure Date:
7 The New Mexico VA Health Care System Director assesses hiring practices for providers and scheduling staff and ensures positions are filled timely.
Closure Date:
8 The New Mexico VA Health Care System Director updates the New Mexico VA Health Care System policies, Consult Management, and Failure to Report for Scheduled Clinic Appointments, to meet Veterans Health Administration policy.
Closure Date:
9 The New Mexico VA Health Care System Director ensures outpatient mental health staff follow Veterans Health Administration requirements for no-show patients and monitors compliance with this process.
Closure Date:
10 The New Mexico VA Health Care System Director confirms that the Administrative Investigative Board recommendations and action plans are completed as required by VHA and managers monitor compliance.
Closure Date:
11 The New Mexico VA Health Care System Director ensures the Administrative Investigative Board process includes identification of relevant documents, records, and other information pertinent to the issues of an investigation.
Closure Date:
12 The New Mexico VA Health Care System Director evaluates the practice of marking outpatient mental health consults as complete without an appointment and without documenting a mental health risk evaluation and takes action as necessary.
Closure Date:
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| 18-04132-163 | Alleged Inadequate Response to a Missing Patient and Safety Concerns at the Bay Pines VA Healthcare System, Florida | Hotline Healthcare Inspection | ||
1 The Bay Pines VA Healthcare System Director develops a policy to address patients with look-alike or soundalike names, educates staff on the use of the policy, and monitors compliance.
Closure Date:
2 The Bay Pines VA Healthcare System Director implements missing patient documentation training for staff, and monitors compliance.
Closure Date:
3 The Bay Pines VA Healthcare System Director ensures that staff responsible for contacting outside facilities for missing patients receive training on their duties and responsibilities, and monitors compliance.
Closure Date:
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| 17-05835-165 | Alleged Interference and Failure to Comply with the Pain Management Directive and the Opioid Safety Initiative at the VA Northern Indiana Health Care System, Fort Wayne, Indiana | Hotline Healthcare Inspection | ||
1 The Veteran Integrated Service Network 10 Director ensures a case consult is made to Veterans Health Administration’s National Center for Ethics to consider whether the Chief of Staff used the position of authority in a manner intended to induce a patient management action which would have otherwise not been taken and, if so, whether the Chief of Staff’s conduct comports with a proper ethical standard.
Closure Date:
2 The Northern Indiana Health Care Director verifies that the Pain Management Committee is providing oversight and monitoring of pain management activities as required by Veterans Health Administration policy and monitors compliance.
Closure Date:
3 The Northern Indiana Health Care Director ensures monitoring of the quality of pain assessments and the effectiveness of pain management interventions and monitors compliance.
Closure Date:
4 The Northern Indiana Health Care Director develops and implements a process to evaluate the success of meeting the goals of the Veterans Health Administration National Pain Management Strategy on a regular basis, at least yearly.
Closure Date:
5 The Northern Indiana Health Care Director establishes a formal transfer process for tertiary, interdisciplinary pain rehabilitation program referrals as required by Veterans Health Administration’s stepped care model for pain management.
Closure Date:
6 The Northern Indiana Health Care Director evaluates the educational programs offered to providers related to pain management and opioid safety to determine if the programs meet the intent of the Veterans Health Administration Pain Management Strategy for standardizing training and competencies and ensure that providers attend regularly.
Closure Date:
7 The Northern Indiana Health Care Director ensures that the pain management team is operational as required by Veterans Health Administration.
Closure Date:
8 The Northern Indiana Health Care Director ensures that the system policy is followed for providers to routinely review an opioid risk assessment for patients on long-term opioid therapy and monitors compliance.
Closure Date:
9 The Northern Indiana Health Care Director verifies compliance with the system’s pain management policy regarding patients’ requests to change providers and monitors compliance.
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10 The Northern Indiana Health Care Director makes certain that primary care providers are utilizing the prescription drug monitoring program as required by Veterans Health Administration when prescribing opioid medication and monitors compliance.
Closure Date:
11 The Northern Indiana Health Care Director ensures that primary care providers receive education on safe and effective Veterans Integrated Service Network tapering programs for patients using the combination of benzodiazepines and opioids and monitors compliance.
Closure Date:
12 The Northern Indiana Health Care Director ensures that providers receive education on tapering programs for patients on high-risk opioids and monitors compliance.
Closure Date:
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15039